HIV and ID Observations

Mather and Company, 1929.

In no particular order, 20 things I’ve found interesting lately — a mix of ID (mostly), language quirks, clinical stuff, even tennis, and an apology (#21) at the very end. Bonus videos embedded because we all need a break.

1. Isn’t it amazing how, over time, an antibiotic once considered “broad spectrum” later becomes the drug we use after the term “narrowed?” Example:  “He was on meropenem, but his cultures came back with just Strep mitis, so we narrowed him to ceftriaxone.” Fair enough — it’s narrower than meropenem — but it’s crazy that ceftriaxone is now a “narrow” antibiotic!

2. Someone who has scant knowledge about healthcare — but has nonetheless risen to a position of power and influence — said that “50 percent of revenues to most pediatricians come from vaccines.” What the …? You might as well say that they get the other 50% by charging for the stickers they hand out at the end of the visit. In fact, pediatric practices take on financial risk and incur high up-front expenses to have vaccines available; for some, providing and administering vaccines can lose money.

3. On the topic of pediatrics, childhood hospitalizations last year from mycoplasma did indeed sharply increase, accounting for half of hospitalized children with pneumonia. We also saw way many more cases in adults, including many with those strange non-respiratory presentations (rashes, neurologic disorders, hemolysis). While cyclic variations in mycoplasma incidence are expected due to waning immunity, this past year saw a bigger increase than usual.

4. I’m not gonna lie — it has always amused me that many people (including me!) highlight certain comments with, “To be perfectly honest…” What does this imply about when we don’t say this? That we’re not being honest? And yes, “I’m not gonna lie,” “truth be told,” “truthfully,” and the rest of the bunch all fall into the same category.

5. A patient I’ve been following for years had a CD4 nadir of 3 at the time of their HIV diagnosis in 2010; it’s now over 2000, an astounding increase. Meanwhile, a similar patient I saw recently has had virologic suppression for almost as long, and the absolute CD4 count still can’t quite crack 100. This variation in immune response to antiretroviral therapy is one of the unsolved mysteries in HIV medicine.

6. Learned recently that pair of words that is used in a fixed order in an idiomatic expression is called an “irreversible binomial.” You know — wet and wild, mac and cheese, wear and tear, rock and roll. The first ID one that came to mind? Glucan and galactomannan — fungal diagnostics aficionados will agree, no one says it the other way

7. The continued universal susceptibility of Treponema pallidum and group A strep to penicillin remains a great gift to humankind, one we should be grateful for every day.

8. We complain about electronic medical records a bunch, but let’s face it — they have made a whole lot of things better than back in the pre-digital age. Near the top of the list? The ability to review radiographic studies without having to trek to a reading room, where the films may or may not be available. It’s especially great since we can now use Teams or Zoom to review the images with our radiologists, with them highlighting the areas of greatest interest.

9. How does anyone ever learn English?

10. We’ve had BCID (Blood Culture Identification) testing in place for around a year now; it rapidly identifies the bacteria in positive blood cultures, and tests for genetic determinants of common resistance mechanisms, too. Trust me — once you have this in place, you can’t imagine ever going back.

11. Even a year after my rant, and over a decade since generic tablets hit the market, some clinicians still think linezolid is too expensive. That’s because patients go to pharmacies, get told their insurance won’t cover it, and aren’t told they can just pay out-of-pocket at a reasonable price. Even worse, one large chain still charges a crazy high price, presumably for the branded version. Because they can? It’s madness.

12. I used to pride myself on knowing all of the FDA-approved cephalosporins, including obscure oral formulations. Confessing right here that the blizzard of recently approved and late-stage compounds (most of them cephalosporin-beta lactamase inhibitor combinations) has challenged this party trick. Let’s see — there’s already ceftazidime-avibactam, ceftolozane-tazobactam, cefepime-enmetazobactam, and cefiderocol; coming soon will be cefepime-zidebactam and cefepime-taniborbactam. Wow.

13. By the way, in addition the cephalosporins, I can also name the fluoroquinolones that were withdrawn due to safety issues — temafloxacin, sparfloxacin, gatifloxacin, grepafloxacin, and trovafloxacin. Branded Zagam, Trovan, Raxar, Tequin, they sounded like action figures fighting it out in an animated science fiction movie. Fun times!

14. Which reminds me: A resident recently told me they couldn’t go into ID because it required “too much memorization” — antibiotics and microbiology, specifically. My reply: it’s not like you become an endocrinologist by spontaneously deriving the hormonal feedback loops. Every specialty has its learning curve. Memorization follows interest.

15. Since the topic of party tricks came up (Name that cephalosporin! That discontinued quinolone!), I often find myself watching videos of card tricks with amazement, admiring the talent of people with a large repertoire. This guy, who says he has a million such tricks, is my favorite of many such magicians — something about his very regular-sounding voice makes him tremendously appealing:

16. Since those were Keith Haring playing cards — you noticed, right? — I must cite that IAS 2025, the 13th IAS Conference on HIV Science, happened this week in Kigali, Rwanda. Not surprisingly, there were several presentations on disruptions in patient care resulting from recent policy changes and budget cuts by the USA — disruptions that will lead to more HIV infections and more HIV-related deaths. Sad to see this proud chapter in U.S. foreign policy come to an end.

17. The letters to the editor at NEJM protesting the Sounding Board written by Drs. Vinay Prasad and Martin Makary on vaccines for COVID-19 make fascinating reading, as does Prasad’s and Makary’s response to the correspondence. It’s remarkable how a group of intelligent, experienced, and well-meaning people can look at the same body of evidence in medicine and come up with starkly different interpretations. I think both sides having valid points.

18. Related, what I’d really like to see is Prasad — who is a strong advocate of evidence-based medicine — take aim at some of the quite outlandish statements we’ve heard about the epidemiology and causes of autism, or the perils of seed oils. Hey, why not? He’s never been shy about voicing his opinion in the past.

19. My favorite new phrase mobilized by our ID fellows when coming up with a treatment plan for an ID consult? Course it out. “He’s improved on cefepime day 3 empirically for pneumonia; I think we can course it out with 4 more days and sign off.” Love that phrase — “course it out” — now a part of our service lingo. Plus, 3+4 = 7. Because of course it does.

20. Congratulations to Jannik Sinner, who blitzed his way past Carlos Alcaraz in this year’s Wimbledon final, as well as Iga Świątek, who “bageled” Amanda Anisimova, 6-0, 6-0. But the best single point of the competition? I’d give the nod to old-timer (38!) Novak Djokovic who, on his way to a semifinal finish, pulled this one off in an earlier round:

21. I was hard on Djokovic in the past when the guy refused to get the COVID-19 vaccine, comparing him to a bully athlete from my school days, but he has really grown on me. In my defense, the world was crazy those first 2 years of the pandemic; I wasn’t always so tolerant. Which is why I was delighted to read a piece entitled Novak Djokovic, I Was Wrong About You, as it summarizes my current views on him perfectly.

So my apologies, Novak!

“Dr. Sax, what’s it like to have lived through two pandemics as an ID doctor?”

The question came from a brand-new intern during afternoon sign-out. I took a breath — because wow, were they different.

HIV: It Felt Like A Calling, One Miraculously Rewarded

I started my internship in 1987, six years after the first cases of AIDS were reported. The median survival of someone newly diagnosed with AIDS was 12−18 months. When, at the end of my three-year residency, I chose Infectious Diseases as a specialty, part of the rationale was to follow what felt like an urgent mandate:  HIV was about to become the leading cause of death among young men in the United States.

(I also liked antibiotics, microbiology, and taking patient histories about travel and pets. You know, the nerdy ID stuff.)

This catastrophic new disease taking the lives of young people in our country didn’t just present a medical challenge. The stigma was brutal. Many clinicians reinforced it by asking how someone acquired the virus, even when the information was in the chart or had no impact on treatment. “How many partners?” “IV drugs?” “Why didn’t you use condoms? I sure hope you do now.” Patients loathed the inquisition and the implied accusations; most of them already felt deeply stigmatized by their diagnosis.

One gastroenterologist, after doing an endoscopy, memorably told a 28-year-old patient of mine with candida esophagitis, “You don’t look like someone who has AIDS. How did you get it?” She remembers that 30 years later, and so do I.

It’s hard to convey just how ubiquitous, and punishing, this stigma was back then. “We can’t have those people taking up an ICU bed,” a cardiologist grumbled to me in 1990. Those people. Some surgeons looked for any excuse to avoid operating on a patient with HIV. Hospitals deliberately downplayed HIV as an area of expertise, not wanting to be branded an “AIDS hospital.”

I’m embarrassed to write that even some ID doctors followed this unfortunate plot line, expressing concern that HIV might ruin our specialty. Why take care of someone with advanced HIV disease when there was nothing that you could do to treat the underlying problem, the virus itself? Send them back to their primary providers for palliative care once you’ve treated the toxoplasmosis or pneumocystis, they argued. Small in number (fortunately), this group of ID doctors did not distinguish themselves during this period.

Because they were wrong. There was plenty we could do, and it wasn’t just diagnosing, treating, and preventing the opportunistic infections. We could also help alleviate chronic symptoms, manage polypharmacy, provide a longitudinal, compassionate care team, and — this part was critical — we could follow closely the research on antiretroviral therapy gathering steam in the laboratories and clinical trials.

When successful HIV treatment arrived in 1996, we could then celebrate with our patients the transformation of their previously fatal disease into something quite treatable. Rejoice!

Today, remarkably, HIV is easier to manage than many chronic conditions. In a quiet signal of triumph over the inevitable downward course of untreated HIV, residents who admit someone with stable HIV to the hospital — usually for a completely unrelated reason — list HIV way down on the patient’s problem list, something in the background that deserves mention but is rock-solid stable.

COVID-19:  A 2-Year Siege That Drained and Divided Us

March 2020 reversed that script. Critically, this time, we ID folks weren’t alone; the whole medical center mobilized.

Energy to respond clinically was both collaborative and, at least initially, sustaining. In those first months, we worked together with critical care specialists, emergency room personnel, the microbiology lab, nursing, respiratory therapists — everyone on the front lines of patient care chipped in to get it right.

Another big difference was that, due to the mode of transmission, the fear was everywhere: every PPE donning felt like bomb-squad duty. Is it weak of me to admit that each time I entered the room of a suffering, coughing patient with COVID-19 in the spring of 2020 that my heart rate quickened? That I repeatedly checked my N-95 mask for the proper seal? Cursed with a giant nose, I had always considered this feature of my anatomy a cosmetic challenge, not a life-or-death issue — but it sure made fitting an N-95 mask difficult.

(Too much information? Sorry.)

I remember a woman from the Dominican Republic, struggling with COVID, telling me — through an iPad interpreter — that she drew strength from memories of going to church as a child. Her faith, she said, was helping her fight the virus. I listened, nodding, but from the far side of the room. The connection felt intimate; my posture and location, not so much.

Hallways were eerie and quiet — administrators were remote, many non-essential clinicians sidelined and doing only video visits, all elective surgery canceled, and family and friends of patients barred from visiting their sick loved ones. That last one was particularly heartbreaking. What a terrible time.

Then, the summer of 2020 teased us with a very welcome pause, as COVID practically disappeared from northern cities like Boston. Phew, time for a deep breath, everyone. I remember postulating hopefully, wishfully, to a close friend that perhaps the virus had already targeted the vulnerable, either from immunologic or genetic factors still to be determined; maybe it was done wreaking havoc on society at large.

I was so very wrong. The next 18 months brought us an autumn/winter surge almost as bad as the first one. Delta the following summer filled ICUs with the unvaccinated; Omicron then infected everyone else within weeks, making the Christmas holidays in 2021 a blur.

We in ID watched each of these waves unfold, following the scientific advances closely, and doing our best to communicate this knowledge to our patients and an increasingly weary public who just wanted this virus gone. Monoclonal antibody treatments came and went as the variants mutated — each antibody challenging to obtain with limited supply, and as difficult to deploy as they were to pronounce.

(It will be quite the trivia question one day to ask ID doctors to say, or spell, bamlanivimab, casirivimab, and imdevimab.)

Alas, our hard work put us in growing conflict with a world ready to move on. Anytime we modified our guidance due to evolving evidence as the disease changed, our words were seized as a signal we weren’t to be trusted. Ivermectin enthusiasm and anti-vaccine rhetoric spiraled into mass delusion. Two extremist camps battled it out in the press and social media — the group that insisted the whole thing was a fraud from the start versus those who refused to acknowledge that the disease had lessened in severity over time.

We knew that the truth lay somewhere between these two groups — yes, COVID was still with us, causing some unfortunate people to become severely ill or leading to Long COVID, but no, it was nowhere near the threat it was in the first 2 years. Somehow, conveying this message led to increasingly cantankerous pushback from both camps.

What began with a collaborative spirit to fight a global pandemic evolved into a political fracture that still hasn’t healed. It was the toughest 2 years of my career, and I’m still not over it.

Some Lessons Learned

Back to that intern’s excellent question, because in our workroom, I probably didn’t give it sufficient thought when I answered, motivating this post.

Yes, they were different. There’s no better example of how different than to look at what happened to Dr. Anthony (Tony) Fauci. Celebrated for leading the response to HIV, pilloried for the same leading role with COVID, he eventually needed a security service to protect himself and his family — one of the saddest commentaries on our divided world one could imagine.

But both viruses exposed societal ignorance and healthcare inequities. The best responses involved teamwork, compassion, rigorous evaluation of the latest research, and nuanced communication.

And both reinforced the fact that our work is never boring, that’s for sure. ID is still the best job in medicine, even when it breaks your heart.